Other·May 22, 2026

42 C.F.R. § 483.25 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. 22 CR §72311 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: 1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (E) Any untoward response or reaction by a patient to a medication or treatment. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). 22 CCR § 72313 Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. 22 CCR § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 4/6/2026, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. Resident 98, was admitted to the facility with a diagnosis of pneumonia and had a history of shortness of breath or trouble breathing when sitting at rest. Over the course of approximately eight hours, the nursing staff failed to notify Resident 98’s physician that he had developed ongoing respiratory distress and failed to provide respiratory assessments as ordered. The facility failed to: 1. Identify Resident 98’s care needs based on assessment of a change of condition (COC) after Resident 98 developed wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs) and required a breathing treatment and oxygen administration in accordance with the facility’s policy and procedure (P&P) titled, “Change in a Resident’s Condition” dated 3/2023. 2. Document on the Medication Administration Audit Report any oxygen administered to Resident 98 on 2/14/26 after the resident’s new onset of wheezing. 3. Administer treatment as prescribed in the physician’s order and implement the care plan, both of which indicated to monitor Resident 98’s oxygen saturation, since the weights and vitals summary does not indicate that Resident 98’s oxygen was monitored on 2/14/26. The facility did not document respiratory assessments (lung sounds and respiratory rate) after nursing staff administered Resident 98’s breathing treatments (inhaled medications that help open airways or reduce inflammation in the lungs) as needed or requested (PRN). 4. Timely notify the attending licensed healthcare practitioners of the change in Resident 98’s condition. 5. Implement the policies and procedures titled, “Charting and Documentation” dated 7/2017, that require indicated vital signs to be taken on change of condition when Resident 98’s heartrate and respiratory rate were not recorded during the 3 p.m. to 11 p.m. shift on 2/14/2026 and 11 p.m. to 7 a.m. shift on 2/15/2026. As a result, there was a delay in identification of respiratory distress and delayed hospitalization for Resident 98. Resident 98 was transferred to the general acute care hospital (GACH) eight (8) hours after experiencing a change in condition and diagnosed with hypoxic respiratory failure (medical condition where the lungs cannot get enough oxygen into the bloodstream) and septic shock (condition where a severe infection causes widespread inflammation and extreme drops in blood pressure). Resident 98 was intubated and admitted to the intensive care unit (ICU). On 3/4/2026, Resident 98 was terminally extubated (medical procedure of removing an endotracheal tube [breathing tube) and the stopping of a ventilator [breathing machine] in a resident whose condition is terminal or not expected to improve) and placed on palliative care (specialized form of care that focuses on symptom relief and comfort for people living with serious illnesses). A review of Resident 98’s face sheet (Admission Record) indicated Resident 98, was an 88-year-old male, initially admitted to the facility on 1/2/2015 and readmitted on 2/13/2026. Resident 98’s diagnoses included pneumonia (an infection/inflammation in the lungs), sepsis, myocardial infarction (MI- heart attack), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). A Resident 98’s History and Physical (H&P) dated 2/14/2026, indicated Resident 98 was able to make needs known but had a fluctuating capacity to understand and make medical decisions. A review of Resident 98’s Minimum Data Set (MDS- a resident assessment tool), dated 2/15/2026, indicated Resident 98 was dependent on staff for toileting, bathing and personal hygiene. The MDS indicated Resident 98 had shortness of breath or trouble breathing when sitting at rest. A review of Resident 98’s care plan titled, “Resident is at risk for respiratory distress related to pneumonia, chronic respiratory failure, anemia” dated 2/13/2026, the care plan indicated to assess Resident 98 for shortness of breath, irregular respirations, wheezing, crackles ((clicking, rattling, or crackling noises made by the lungs caused by the sudden opening of small airways plugged with fluid or mucus), rhonchi (low-pitched, continuous, snoring-like lung sounds indicating obstruction in the large airways), coughing, and weakness, inform the physician promptly, and monitor O2 sat as needed/ordered. A review of Resident 98’s physician orders dated 2/13/2026, the physician order indicated, “Monitor O2 sat every shift.” A review of Resident 98’s physician order dated 2/14/2026, indicated to administer oxygen at 2 liters per minute via nasal cannula (flexible tube used to deliver oxygen directly into a patient’s nostril’s), may titrate (adjusting the flow rate of supplemental oxygen up or down to achieve a specific target blood oxygen saturation level) up to 5 liters per minute for O2 sat less than 92% as needed for shortness of breath. A review of Resident 98’s Weights and Vitals Summary dated 2/14/2026 indicated Resident 98’s O2 sat, heartrate, and respiratory rate were documented on 2/14/2026. A review of Licensed Nurses Note dated 2/14/2026 and timed 11:01 p.m., indicated on 2/14/2026, LVN 2 observed Resident 98 wheezing and administered a PRN breathing treatment. “LVN 2 stated on 2/14/2026, she noticed Resident 98 was wheezing when she was rounding at the end of her shift, around 11 p.m. LVN 2 stated Resident 98’s O2 sat levels fluctuated between 94 % to 96% (normal range 90-100%). LVN 2 stated she asked LVN 4 to call Resident 98’s physician for an order for oxygen and placed Resident 98 on 2 liters of oxygen before the end of her shift.” The note indicated Resident 98 was restless, removing his clothing, and required supervision during the breathing treatment due to Resident 98 removing the nebulizer mask (plastic device connected to a machine that turns liquid medicine into a fine mist). A review of Resident 98’s Medication Administration Audit Report (MAAR- report that evaluates the accuracy and documentation of medication administration) dated 2/14/2026 did not indicate that oxygen was administered to Resident 98. A review of Resident 98’s MAAR dated 2/14/2026 indicated, on 2/14/2026 at 11:11 p.m., Acetylcysteine (medication that helps loosen secretions and clear airways) Solution 10 % PRN breathing treatment was administered. A review of Resident 98’s physician’s order dated 2/15/2026 at 1:42 p.m., indicated to transfer Resident 98 to the GACH due to shortness of breath and low O2 sat. A review of Resident 98’s Licensed Nurses Note dated 2/15/2026 and timed 7:36 a.m., indicated Resident 98 was transferred to the GACH via 911 due to low O2 saturation reading at 85 percent (%) on 5 liters of oxygen. A review of Resident 98’s GACH Emergency Department (ED) Notes dated 2/15/2026 at 7:54 a.m., indicated Resident 98 was transferred to the ED for complaints of hypoxia (a life-threatening condition where the body’s tissues and organs do not receive enough oxygen to function properly) and hypotension (low blood pressure) and diagnosed with septic shock and hypoxic respiratory failure secondary to pneumonia. The GACH ED Notes indicated Resident 98 was hypoxic, hypotensive, and intubated. A review of Resident 98’s GACH Physician Progress Notes dated 3/4/2026 at 10:23 a.m., indicated Resident 98 had a poor prognosis. Resident 98’s family planned for terminal extubation. A review of Resident 98’s GACH Palliative Care Progress Note dated 3/4/2026 at 7:13 p.m., indicated Resident 98 was extubated with PRN orders for morphine and Ativan for dyspnea (difficulty breathing) and distress. During an interview on 4/8/2026 at 3:52 p.m. Licensed Vocational Nurse (LVN) 2, stated towards the end of her shift, Resident 98 became restless, with his feet dangling at the edge of the bed. Resident 98 may have been restless because it was difficult for him to breathe. LVN 2 stated the new onset of wheezing, restlessness, and need for oxygen administration should have been considered a COC. LVN 2 stated she endorsed Resident 98’s change in condition to the oncoming nurse (LVN 3) but did not document. A COC assessment should have been completed to ensure licensed nurses were properly taking care of and addressing Resident 98’s respiratory needs. Failure to complete a COC assessment placed Resident 98 at risk of delayed identification of respiratory complications such as respiratory distress, and delayed hospitalization. LVN 2 stated she placed Resident 98 on 2 liters of oxygen after administering his PRN breathing treatment. She (LVN 2) did not document the oxygen administration. Oxygen was a drug and its effectiveness needed to be monitored. Documentation of oxygen administration was important to ensure other staff were aware of Resident 98’s oxygen needs and to assess the effectiveness or need for oxygen titration. LVN 2 stated she checked Resident 98’s vital signs during her shift but did not document. Documenting vital signs were important to establish a baseline for each resident, help nursing staff identify changes, and intervene. She (LVN 2) administered the PRN breathing treatment on 2/14/2026 at 11:11 p.m. because Resident 98 developed wheezing. LVN 2 stated she did not reassess Resident 98’s O2 sat after the PRN breathing treatment. LVN 2 stated she did not ensure Resident 98 received adequate oxygenation nor ensure the breathing treatment was effective. Reassessing residents after PRN treatment helped nursing staff determine if additional interventions, or physician notification were needed. During a telephone interview on 4/8/2026 at 1:27 p.m. LVN 3 stated a COC assessment was not completed to address Resident 98’s new onset of wheezing and need for oxygen. LVN 3 stated she could not recall if LVN 2 reported Resident 98’s new onset of wheezing and oxygen requirement and did not realize a COC should have been completed during her shift. Failure to complete a COC assessment placed Resident 98 at risk for unaddressed respiratory complications such as respiratory distress. LVN 3 stated on 2/14/2026, Resident 98 was already on oxygen when she started her shift (11 p.m. to 7 a.m.). LVN 3 stated she should have ensured oxygen administration was documented. LVN 3 stated the lack of documentation placed Resident 98 at risk of improper monitoring. Residents’ clinical records should accurately reflect the care and treatment they receive. LVN 3 stated on 2/14/2026, she checked Resident 98’s oxygen saturation and blood pressure once during her shift but did not document the findings. Resident 98’s vital signs should have been documented to ensure the resident’s vitals trends were monitored and appropriate interventions implemented to address any deviations from the resident’s baseline. LVN 3 stated failure to document vital signs placed Resident 98 at risk of delayed respiratory distress identification and intervention. She (LVN 2) checked Resident 98’s O2 sat once throughout her shift but could not recall when. LVN 3 stated on 2/15/2026 around 3:00 a.m., she administered the PRN breathing treatment. LVN 3 stated she did not assess Resident 98’s O2 sat or lung sounds after administering O2 to Resident 98 to ensure the breathing treatment was effective. LVN 3 stated because Resident 98 was a new admission, developed a new onset of wheezing, and required oxygen, she should have assessed Resident 98’s lung sounds and O2 sat level more frequently throughout her shift. LVN 3 stated lack of respiratory assessments and monitoring, placed Resident 98 at risk for delayed identification of respiratory distress and delayed hospitalization. During an interview on 4/9/2026 at 1:54 p.m. the Infection Prevention Nurse (IPN), stated because of Resident 98’s history of respiratory failure and new onset of wheezing, nursing staff should have assessed Resident 98’s respiratory status and O2 sat more frequently. The IPN stated that lack of monitoring placed Resident 98 at risk for delayed identification of hypoxia and delayed hospitalization. During an interview on 4/9/2026 at 9:00 a.m. the Director of Nursing (DON), stated a COC assessment should have been completed when LVN 2 determined Resident 98 was wheezing and required oxygen administration. COC assessments were important because they ensured a comprehensive assessment was completed and allowed the physician to place additional orders to address the residents’ needs. Failure to complete required assessments placed Resident 98 at risk for respiratory complications such as respiratory distress. Resident 98’s oxygen administration should have been documented. The DON stated that documenting oxygen administration was important to ensure effectiveness was monitored. Documentation of vital signs was important to identify and address any abnormal vitals. Documentation gives the care team a comprehensive view of the residents’ condition and drives additional in